Providers who refer, order or prescribe for Medi-Cal beneficiaries must enroll with DHCS

November 09, 2015
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement Practice Management 

Under the Affordable Care Act, all providers who order, refer or prescribe (including but not limited to physicians, nurse practitioners and physician assistants) for Medi-Cal beneficiaries must be enrolled in the Medi-Cal program. Previously, providers needed to enroll only if they wished to furnish (and bill for) covered services for Medi-Cal beneficiaries. 

If an ordering and/or referring provider (ORP) is not enrolled in Medi-Cal, the "filling providers" (for example, the pharmacy that is filling the patient’s prescription or the specialist you are referring a patient to for treatment) will not be paid. As a result, patients may not receive needed items or services if the “filling providers” refuse to accept orders or referrals from providers who are not enrolled in Medi-Cal.

Although the new requirement went into effect January 1, 2013, the California Department of Health Care Services (DHCS) established a grace period to allow more providers to enroll before turning the edit on and denying claims. During this grace period, DHCS has been issuing a Remittance Advice Determination (RAD) code of 0556, “ORP prov not enrolled, correct or future claims will not pay” to “filling providers.”

DHCS reports that a high number of ORPs have still not enrolled with DHCS, thus threatening payment to “filling providers” once the ORP edit is turned on in its system. While DHCS hasn’t yet started denying claims, the grace period could end at any time. Ordering and/or referring providers are therefore encouraged to complete the enrollment process as soon as possible. Additionally, practices that are seeing code 0556 on their RADs should reach out to the ORP about enrolling.

ORP providers are providers who enroll for the sole purpose of ordering, referring or prescribing to covered beneficiaries and who do not directly submit claims for their services. Please note that this type of enrollment does not allow the Medi-Cal program to reimburse the ORP—only providers who provide services directly to Medi-Cal beneficiaries.

Providers who are already enrolled in Medicare or Medi-Cal under their individual (type 1) National Provider Identifier (NPI) number do not also have to enroll as ORP providers.

Providers that may be affected by this change include individual physicians or physicians employed by physician groups, federally qualified health centers, rural health clinics, critical access hospitals, the Department of Veterans Affairs, Department of Defense TRICARE program and the Public Health Service.

For more information, or to enroll as an ORP provider, visit the DHCS website. The ORP enrollment form is DHCS 6129.

For questions regarding enrollment as an ORP provider, contact the DHCS Provider Enrollment Division at pedcorr@dhcs.ca.gov or (916) 323-1945.


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